Student Medication Release Form

Student Medication Release Form

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Consult with your child’s physician prior to travel regarding any regularly taken medications and confirm dosage and timing (taking into consideration time zone changes in the field). Please be sure to pack any prescription or over the counter medications not listed on this form that your student may need over the course of their GO trip in a Ziploc bag labeled clearly with their name and a copy of this form. Also, ensure that any allergies or other health considerations are included in their Managed Missions profile.

Minor Information

Minor's Name*

FirstLastGoes By

GO Team*

GO DENTAL Ecuador (Ellen P.)

GO MEDICAL Ecuador 1 (Renee M.)

GO MEDICAL Ecuador 2 (Russell L.)

GO GREECE (Shawn H.)

GO GUATEMALA Latino 1 (Kaitlyn G.)

GO GUATEMALA Latino 2 (Johanna W.)

GO DEEP Haiti (Shanae H.)

GO DEEP Haiti Students (Christie B.)

GO HONDURAS College (Jon S.)

GO HONDURAS Student Leaders (Jeff F.)

GO INDIA (Kelli M.)

GO INDIA College (Melinda P.)

GO JAARS Family 1 (Lynne L.)

GO JAARS Family 2 (Scott B.)

GO JAARS MS Student Weekend (Jacob N.)

GO LOCAL Camp TRAC 1 (June 18-21)

GO LOCAL Camp TRAC 2 (June 25-28)

GO DEEP Palestine (Kelli M.)

GO POLAND Kontakt (Angel D.)

GO POLAND Shine (Miki A.)

GO POLAND Students (Jason T.)

GO POLAND Student Leaders (Lesha T.)

GO RWANDA Student Leaders (Keith P.)

GO SPAIN Prayer (Krista T.)

GO TENNESSEE Family (Celeste C.)

GO TENNESSEE HS Students (Sean R.)

GO TENNESSEE MS Students 1 (Kathy S.)

GO TENNESSEE MS Students 2 (Isis B.)

GO UKRAINE (Marc P.)

GO ZIMBABWE 1

GO ZIMBABWE 2 (Joe M.)

GO MEDICAL Zimbabwe (Kelly W.)

Select all the GO Teams on which you are currently a member. Teams are listed in alphabetical order by location.

Parent/Guardian Name*

FirstLastRelationship

Contact Information

Home PhoneCell PhoneEmail

Prescription Medication

Medication #1

MedicationDosageWhat TimeReason For Taking

Medication #2

MedicationDosageWhat TimeReason For Taking

Medication #3

MedicationDosageWhat TimeReason For Taking

Medication #4

MedicationDosageWhat TimeReason For Taking

Consent for Administration of Prescription & Over the Counter Medications

Please indicate whether or not you would prefer for your student or an adult team leader to be responsible for both storing and administering any prescribed medications in the field by checking the appropriate box below. Note that for security reasons students must travel with their own prescription medications packed in their personal carry-on and if indicated below will give them to a team leader once they have reached their destination.

I would like my student to keep prescribed medication in his/her possession and administer themselves as directed

I would like an adult leader on the team to be responsible for both keeping and administering my student’s prescribed medication in the field

Over The Counter Medications

The following non-prescription medications will be carried by the GO Team Leader(s) and made available as needed to team members. Please check the boxes below to indicate all medications you consent to your child receiving in the recommended doses without requiring that you be contacted from the field.

I acknowledge that all the information provided on this form is accurate and complete and consent to my child receiving their prescription medication as indicated as well as the over the counter medications I have indicated on the previous page without requiring additional consent at the time of distribution.